Talk doesn't pay: Comments on the NY Times article

March 6th, 2011

I’d like to take this opportunity to comment on the article that appeared in today’s New York Times: “Talk doesn’t Pay, So Psychiatry Turns to Drug Therapy.” Gardiner Harris writes about psychiatry’s shift from talk therapy to drugs, and profiles psychiatrist Donald Levin of Doylestown, PA (a suburb of Philadelphia), who felt financially unable to maintain a psychotherapy practice, and therefore shifted to a high-volume, medication-only practice. It is clear that both the doctor and the journalist consider this a sad state of affairs. Dr. Levin is quoted as saying: “I’m good at it, but there’s not a lot to master in medications. It’s like ‘2001: A Space Odyssey,’ where you had Hal the supercomputer juxtaposed with the ape with the bone. I feel like I’m the ape with the bone now.”

That comparison is apt to rile my colleagues who are serious and careful psychopharmacologists. But Dr. Levin is right: Most medication management in psychiatry is tediously straightforward. Which is why it is mostly done by primary care doctors, not psychiatrists. In the U.S. most antidepressant and antianxiety prescriptions are written by non-psychiatrists. (And even antipsychotics lately, but this is a different and far more worrisome issue.) It seems to me that any self-respecting psychiatrist who limits his or her practice to psychopharmacology, i.e., medication management only, should add some value over a visit to a family doctor, internist, or pediatrician. Either the cases seen should be harder, e.g., “treatment resistant,” or the doctor should offer something more nuanced and sophisticated, or more comprehensive. If so, such a psychiatrist will not be “the ape with the bone.” Unfortunately, my experience suggests this is the exception, and that the shift to medication management has been borne of expediency and financial pressure in many cases, not an earnest scholarly focus on advanced psychiatric medication strategies. And for this reason, the critique that our field is increasingly populated by dumbed-down medication technicians is not the throwaway line it would otherwise be.

In saying this, I invite a rebuttal. If psychiatrists who give meds should add something over other med providers, what do psychiatrists who conduct therapy add over other therapists? The answer is a more comprehensive viewpoint, one that takes into account medical and bodily issues, drug interactions, and similar matters. And the option to prescribe medications when these are needed in addition. If we cannot add this value, we should not charge more than other therapists.

Since I have a mostly-psychotherapy practice myself, I took note of several points made in the article. Most glaring is a starkly misleading statistic. Harris cites a 2005 government survey showing that just 11 percent of psychiatrists “provided talk therapy to all patients.” I’m not sure why that surprises anyone. I’m a huge advocate of psychotherapy, yet I don’t recommend, much less provide, it for everyone. It’s a treatment — it’s expensive, it takes a lot of time, it’s often uncomfortable. I only provide psychotherapy when I predict it will help, and when my patient agrees to it. While I believe it would be helpful for many patients I see, I nonetheless still treat a minority of patients with medication only. In my view, one of the best things about being a psychiatrist is that we have a variety of tools. While I find dynamic psychotherapy more intellectually interesting and humanly engaging than writing prescriptions, I’m glad I can do both. The 11 percent statistic is meaningless.

Another potential confusion in the article are the widely disparate fees cited, with little explanation. At one point Harris writes: “A psychiatrist can earn $150 for three 15-minute medication visits compared with $90 for a 45-minute talk therapy session.” At least here in San Francisco, this is considerably less than either service is typically worth, even accounting for payment caps by health insurers. Not to mention that psychotherapy is traditionally 50 minutes, not 45. But then Harris writes about “a select group of [New York] psychiatrists [who] charge $600 or more per hour to treat investment bankers,” and later notes that a nearby colleague of Dr. Levin charges “$200 for most [therapy] appointments.” The truth in my experience is that no psychiatrist starves by being a psychotherapist, even though there is more competition from other disciplines and the overall income may be less. Talk does pay, just not quite as much. When psychiatrists complain about comparatively low psychotherapy income, it makes me wonder why they didn’t become surgeons. Seriously, from what I gather surgery is very engaging, very satisfying, and very lucrative. It sounds much better than doing half-hearted, half-assed psychiatry just for the income boost.

As I wrote last year, dynamic psychotherapy is more than merely a treatment technique to place on a shelf alongside medications. It is a perspective that informs our understanding of patients even when we do not offer this specific therapy as treatment. Thinking about our patients dynamically can help us be better medication providers, better CBT (non-dynamic) therapists, better referrers to other professionals. Psychiatrists don’t have to be psychotherapists all the time, but we do need to think psychotherapeutically all the time. The real tragedy highlighted by the NY Times article is not one man’s devolution to an “ape with a bone,” nor even a profession’s. It is the loss of intellectual curiosity — of knowing there is a better way, yet choosing not to pursue it.

34 comments to Talk doesn’t pay: Comments on the NY Times article

I agree that psychopharmacology is, for the most part, “tediously straightforward,” and that as a psychopharmacologist I feel at times like a “dumbed-down medication technician.” This not what I expected, nor wanted, to be doing with my time and my clinical expertise.

That said, it is surprising to me how many patients seem to accept this state of affairs. Maybe prescribing really is as easy as it looks.

Thank you for commenting, Dr B. I regret that I didn’t know about your own psychiatry blog until yesterday. And a fine one it is, so I invite my readers to head over to thoughtbroadcast.com and check it out.

I’m left a bit perplexed by your observation, which echoes one in the article we both blogged about, that the public “accepts” this state of affairs. People put up with all manner of mistreatment, from telemarketing at dinnertime to fraudulent investment offers, from long lines at the post office to surly wait staff at restaurants. Why wouldn’t at least some of the public participate in assembly-line “med checks” too? What’s their alternative? Nor does it surprise me that one can find advocates of this approach among the public, as one can find advocates of nearly anything. In my view, and yours too I assume, public acceptance should never be a profession’s standard of quality.

Prescribing really is easy — except when it’s not. This reminds me of what I heard long ago about the specialty of anesthesiology: It’s boring, except when it’s terrifying. Prescribers, whether primary-care docs or psychiatrists, are not paid on the assumption that every case is routine and easy. If we were, we’d get about $10 to see someone for 10 minutes. All the pay beyond that is for recognizing and managing the exceptions.

You’re right… Perhaps the public accepts this practice the same way people with health insurance claim they are “happy” with their coverage: it ain’t great, but it’ll do, and they fear that any change can only make matters worse.

I must admit, though, there is a surprising disconnect between what I think I am offering patients and what they perceive they are getting. Maybe it’s because I’m thinking psychotherapeutically, as you describe in the last paragraph of your post. Even when just doing “med management,” I’m careful not to respond in knee-jerk fashion to each complaint the patient brings to the table, but instead listen to the overall story each patient tells.

I completely agree with this perspective. The NY Times presented a really skewed perspective and did not seem to get many other opinions other than that of Dr. Levin and his wife. Articles like this only worsen the characterization of our field.

For the seriously mentally ill, medication adjustments are not enough. Medical doctors turn a deaf ear to the psychiatric patient. I may not be able to read my psychiatric records but my medicals records are open to me. Not a single visit to my medical doctor went by without a comment on my delusional, psychotic or violent state. Sometime the reason for my visit wasn’t even noted. It took over a year and a half to get a single MRI of my lumbar which had two bulging disc and a herniated disc. I kept pushing and finally thanks to a rash I received medication that eased my cognitive disorder and thereby my psychosis– antihistamines. My doctors have no idea what is wrong with me and I don’t care as long as antihistamines keep working– I’ll take care of myself.

I’m glad I don’t have to see these doctors on a weekly basis anymore to keep prodding them. I really don’t miss the serotonin toxicity and NMS from the antidepressant and antipsychotic either. I was lucky that even in my psychotic and disorganized state that I could still advocate for myself. According to the books I read, advocate for my medical treatment my psychiatrist’s job! I never even received a single blood test from my psychiatrist let alone a medical referral.

I’m glad you doctor find the state of your profession upsetting because as a patient I sure did! Still do!

Thanks for writing, John. Your comment makes me want to clarify something. Most psychiatric medication is not for serious mental illness such as psychosis. It’s for depression and/or anxiety. These can be serious too, of course, but usually they’re not. This is why non-psychiatrists prescribe so much antidepressant and anti-anxiety medication. As I’ve posted before, anyone with psychosis needs to be treated by a psychiatrist. The “ape with a bone” language used in the NY Times article and in my post does not pertain to treating serious mental illness.

Your telling me the average CMHC is prepared to treat the SMI? With the psychiatric nurse to psychiatrist ratio 30 to 1 and 10 minute medication adjustments? We get the same “ape with a bone” treatment.

No, I wasn’t saying that. The average CMHC is underfunded and overloaded, and unfortunately patients there often get the “ape with a bone” treatment. (On the other hand, some CMHCs do a lot of good with very few resources… and sometimes an ape with a bone is better than no ape at all. It’s really a matter of politics and civic priorities.) My point was that routine antidepressant and anti-anxiety meds can safely be prescribed by non-psychiatrist MDs, whereas stronger meds like antipsychotics should not be. Whatever meds are involved, a psychiatrist should be sensitive to psychological issues as well, and psychodynamically aware.

The world does not operate according to psychodynamic principles. Those who think psychopharmacotherapy is easy probably don’t know much about it, but yes, some cases are easy, just like some patients benefit from psychotherapy and others don’t. It’s all about what’s best for the patient. We all make compromises where money is one of the parameters every day. Dr. Levin is no exception. He and the rest of us have a right to practice as we choose considering all the factors. We should be concerned that too few will choose psychiatry. Psychotherapy should never be forced on a patient because the psychiatrist gets a kick out of doing her particular brand. Often with combined treatment you get one-size-fits-all psychotherapy and marginally competent psychopharmacotherapy. I call it sporkiatry. Here’s what it can look like:http://behavenetopinion.blogspot.com/2011/01/sporkiatrist-tries-to-do-psychotherapy.html
BTW: referring to psychiatrists as “therapists” is demeaning as is referring to psychotherapy as “therapy.”

The world operates very much according to psychodynamic principles. And behavioral principles. And biologic, economic, political, and other principles. Since mental and emotional well-being spans so many domains, ideally we psychiatrists would be well-versed in all of human experience, from the cellular to the cultural. In real life that’s impossible, so we do the best we can, by being well-versed in biology and psychology as it relates to alleviating our patients’ distress. In your view that makes us “sporks,” but the same argument devalues primary care doctors or generalists in any field.

It has not been my experience that combined treatment results in generic psychotherapy or marginally competent psychopharm. There are psychotherapies for which I am not trained (e.g., CBT), and complex med issues that are beyond my expertise. I refer those cases out. However, I have a great deal of experience in psychodynamic therapy and typical psychiatric medication evaluation and management. Like a good internist, I can treat the great majority of patients who present to me. I would no more use the same treatment with all of them than an internist would.

Neither psychotherapy nor medications should be forced on a patient because the psychiatrist gets a kick out of his or her favorite approach. Of course, nowadays we hear constantly about knee-jerk prescribing. Knee-jerk therapy, not quite so much.

Dr. Levin has a right to practice as he does — by my reading, he’s not committing malpractice. But even he doesn’t consider it a good approach, and I’m inclined to trust his judgment on that.

Antidepressants maybe routinely be prescribed by PCP but they probably shouldn’t be prescribing to the SMI as you said and PCP may not be qualified to make that distinction. Serotonin toxicity may not kill the patient but it’s probably a really bad idea to be agitating and enraging the SMI with it. (Over and over again … speaking from personal experience with my own PCP who had no idea about serotonin toxicity till I myself brought it up.) The same can probably be said of benzos and other addictive medication as PCP can wind up making a SMI patient into a dual diagnosis patient. (This happen to one of my undiagnosed friends who is now diagnosed with schizophrenia and dealing with an addiction as well.)

I have quite a few SMI friends, I run a support group (two actually, one for schizoids and one for mastocytosis), I have a few friends that have not been diagnosed and these are walking disasters in the hands of well intentioned PCP prescribing psychiatric medications. Are the PCP safely prescribing antidepressant and anti-anxiety meds or are they just lucky that only 2.6% of the population is SMI?

I do understand your point of view but on the receiving end it’s not just an academic discussion we are the ones that suffer in a system ill equipped to deal with us sometimes.

You make excellent points, I don’t disagree at all. Still, we’re stuck with the reality that depression and anxiety lie on a continuum from very mild to very severe. For the mild end of the spectrum there are countless professionals, semi-professionals, complementary/alternative practitioners, well-meaning friends, bartenders, motivational speakers, people on the bus, etc etc who are all out there to “help.” The field narrows considerably for the SMI, but there’s no sharp line of severity that tells everyone except experts to back off.

Appropos my comment just above to “moviedoc”, a generalist should know his or her limitations. In med school I learned that a PCP should successfully treat about 85% of complaints that come through the door, and refer the balance to specialists. I suspect this percentage applies to psychiatric presentations as much as it does for back pain or headaches. In other words, I don’t think PCPs are “lucky” that only 2.6% of the population is SMI, I think good ones take that reality into account, and know they need to refer. And in my view, the same approach applies to general adult psychiatry, where I successfully treat the great majority of patients who present to me, and I refer out a small minority to “subspecialists” such as CBT and DBT psychotherapists, ADHD specialists, head-injury specialists, and so forth.

I’d like to steer the commentary for this post back to the topic of the NYT article, but thanks again for writing.

I hope the NYT left some stuff out, because by my reading, Dr. L is a malpractice suit waiting to happen.

He cut a patient off who wanted to talk more about his troubles. His wife offered someone in a suicidal situation an appointment about a month away.

Malpractice is very difficult to prove, regardless of the hype. But, he would have been liable if either of the above haed committed suicide.

I do not agree that he is free to practice as he pleases, which is to choose the most profitable.

No medical doctor pays the expense of all of the med education, even after repaying the loans. The medical schools exist and are funded to train healers, not businessmen. He clearly feels no social responsibility.

The third party reimbursement system drive up fees all the time and the lifestyles they fund. There are a limited amount of health care dollars.

A doctor who wants more money can find a way to supplement income. I don’t care about his stock market problems. Let him try real estate. Or apply for a job as an insurance executive.

Psychiatrists usually don’t maintain costly exam rooms and equipment. They usually don’t even look down a throat. Their office expenses are less than other doctors.

As someone who was motivated to go to medical school to be a “healer” instead of a businessman (although not completely ignorant of financial matters), I figured that if I was a competent healer, a comfortable lifestyle would follow. My guess is that Dr. L felt this way throughout most of his career.

What I’ve observed in my young career, though, is that doctors are seen as revenue enhancers, resource utilizers, risk generators, and expendable employees, rather than as healers. The patient may still want a “healer” but the system in which we work consistently tells us, directly and indirectly, that we are cogs in this massive health-care machine. Psychiatrists, in particular, are torn between the desire to heal (in ways that are hard to set any “market value” on) and the attention that we are forced to pay to the bottom line– our employers’ and our own.

When doctors are constantly faced with the reality that modern medicine is more of a business than a way to heal, even the slightest patient interaction becomes a cost/benefit calculation. Dr. L didn’t cut off his patients in their time of need because he was a cold, heartless jerk, it was because the cost of spending more time with the patient (and the possible malpractice risk of having this information, as you point out) was greater than the benefit to his practice.

Notice I didn’t say benefit to the patient. In the modern practice of medicine, the patient’s needs are often the last to be satisfied. Paradoxical, yes, and sad.

[PS: I realize I may have been a bit heavy on the cynicism here… but these comments aren’t too far from reality, and sometimes things change only when things are stated in crude, black-and-white fashion.]

The patient is your employer, period. Not the insurance company. What a pity most doctors have forgotten the patient is boss because of third-party payment systems! Most insurance is employment-related. I currently have Medicare, and I am a taxpayer. I have certified clients through a state job as Medicaid. You are most legally liable to the patient, not the third party payer.

Dr. L cut the patients because time is money, not that he feared more time would open him up to more liability. He already had the info. A family doctor or an internist wouldn’t have done that. Even though the more “physical” doctors bill most appointments as 15 minutes, they never say the words “15 minutes.” And often give me more!

I am 55 years old. In the late 60s and early 70s, I heard that a psychiatrist cost $35 an hour. Now Dr. Levin is collecting mostly copayments, which can be as much as $50, for 15 minute sessions.

Don’t you study history of fees? What about lifestyle history? Has the average doctor or dentist’s lifestyle increased dramatically? I say it has.

My younger brother was born in 1958, and was quite sickly his first three years. I recall doctors occasionally making a house call when he was very small.

I was a blue collar child. I used to play with our family doctor’s daughter, who came to our house. I do not think their house was that much more expensive than ours. Now how would an electrician’s house compare to a doctor’s?

Furthermore, up till I was about age 13, doctors billed for their services. Yeah, lots of people stiffed them. Even before that, doctors got paid in produce or whatever.

In my twenties, insurance evolved into a deductible system. Pay a $200 annual deductible and then insurance pays 80%. But no one wanted to take insurance assignment!

In 1987-1989, I was quite ill, frequently having to pay $100 to $150 new patient fees on credit cards. Then along comes the small copayment system.

Okay, my first copayment system was $5 a visit. Then I made the not-too-surprising discovery, and this would not benefit the psychiatrists, that when the patient is only paying $5, a doctor runs every costly test in sight.

I have been to good and back doctors, the greedy and the generous. My dermatologist lives in a $2 million home, but he is a generous man in his practice. Perhaps some of his money is inherited or invested. His priority is sick people, not Botox. He takes my Medicare and bills me for my small portion. He is a busy man, and he has some expensive equipment in his office. But, for me, he only charges for his time. He is always rushed, but he will talk more with me. He is hospital’s Chief of Derm, and always has a resident see me first, but he never abdicates his responsibility.

Since you are a young psychiatrist, surely you realize that the expense of maintaining an office is much less than a family doctor with costly exam rooms and equipment. My current internist refers out for labs and is not making extra money on drawing it in her office. If she makes extra money, it’s from hospitalizations. And the time she spends with me and what she charges, including an exam, is hardly more than a psychiatrist. FYI, it is also now illegal for a doctor to own interest in a lab that draws his or her blood work.

The third party payment systems are socially new. They have inflated fees and lifestyles. And doctors seem to think they should be able to get, oh $200 an hour for therapy, without the existence of insurance.

In my large Southern city, psychiatrists routinely get about $15 copayments for 15 minute med appoints and maybe $25 for the insurance reimbursement. But, if a patient pays out of pocket, they think they are entitled to higher fees, $90.

The practice of charging different rates to different classes, meaning insurance companies, is also bizarre and would be illegal in any other industry. Study trusts, trust-busting, and Teapot Dome.

The much-maligned legal system does not have a third party payer enriching them.

I will allow that American graduating doctors and dentists have already been raped by another system corrupted by third party payment, the universities. But we have to look at the lifestyles doctors and dentists start living shortly after graduation while still repaying loans!

You can be a REAL HEALER. Remember that the patient is your employer. Student loans can be adjusted according to income. Read “The Millionaire Next Door” and see how most people accumulate money. It’s not by looking at government and insurance as sugar daddies.

I’m afraid I don’t agree with either of you in this last round. Doc, a lot of your argument hinges on what a “comfortable” lifestyle is. I still figure that if you’re a competent healer, a comfortable lifestyle follows. Are you comfortable with $100k/yr? 200k? more? Also, you can’t blame “society” for turning you into a businessman. Especially as a psychiatrist, you have the choice to opt out of the “cog in the wheel” model. Hang a shingle, work it out between yourself and your patients. That’s what I do. The only hitch, and I’m sure commenter John would mention it if I didn’t, is that this prices me out of working with most SMI and virtually all indigent patients (although I do see a few on Medicare). Being humanitarian never guarantees a comfortable lifestyle, so you really have no complaint if you’re nice enough to do this kind of work for lower pay. I worked in a CMHC for a couple years early in my career, and I wouldn’t object if that were somehow made mandatory, as a kind of community service.

Betsy, my response to you is very simple. $35 in 1970 dollars equals $200 in today’s dollars. I know that’s hard to believe, but it’s true. See this inflation calculator.

By this standard, I’m undercharging at $175/hr — literally making less per hour than those psychiatrists you remember from 40 years ago.

I want to clarify one thing– I’m not blaming “society” for turning docs into businessmen, I’m blaming our health care system. As regards society, I have a very clear duty (as Betsy pointed out) to care for my patients. Period. The system, however, reminds me at every turn that it exists first to make money (or, at least, not to lose it), and second to care for people. Of all the players involved, the doctor is the one most acutely affected by this perverse dialectic.

Regarding practice settings, I work part-time in a CMHC and part-time in a private practice, so I see both sides of the picture. The community setting, obviously, is where these market forces are played out the most, and yes, I know I have the option to leave and “work it out” privately with my patients. However, I still believe my comments about turning into a “cog in the machine” need to be heard because (a) the community/insurance setting is where most psychiatric care is provided, and (b) if docs like myself (and Dr Levin) don’t speak out against the disrespect we’ve been afforded by those who set the parameters under which we work, then things are only going to get worse.

I remember seeing gas advertised for 19.99 cents a gallon in the 1960s. $35 an hour was what the psychiatrists charged in full, no copayment system.

I think our house payment was about $100 month for a 3 bedroom, 1 bath house. I’d like to know what our family doctor’s house payment was way back way when? Now, what’s a house payment for a modest home? Around $800 month? What do most doctors pay for lavish homes? $1500?

Most doctors in my large Southern city live in $300,000 to $500,000 homes. I’m sorry, folks, you have to accept that it’s easy to check these things on internet property rolls. Property tax rolls have always been public, but we had to go to a courthouse to check them. Certain Standards of privacy no longer apply.

Dr. Reidbord appears to be charging reasonably, though I think it’s excessive. But it’s approx the same as a reasonable internist would charge for a new patient hourly exam that should include examining and touching body parts in a more costly room.

I regret that the third party payment system is here to stay. It’s really corrupted the medical system and the university system.

Doctors now forgot that the patient is the boss. The universities preach social justice while protecting themselves with tenure and great benefits. Meanwhile, the patients and students pay more all the time.

I have never understood the copayment system. In theory, the insurance companies negotiate lower rates with providers. But, in practice, it ends up costing everybody more. Doctors, and this does not include the psychiatrists, run every test they can when the patient is only paying a small copayment.

The copayment, managed care system gives certain providers more business. Are they colluding with the insurance companies? Here’s the real mystery. Surely the average small chain of doctors or an solo doc doesn’t gets kickback, but what about hospitals? As a private doc told me, there is no bargaining with an insurance company. The fee is offered, and it’s take it or leave it.

A savvy patient can discern the financially repsonsible doctors off referrals. Nongreedy doctors don’t repeat tests, even though government and insurance will pay for them at a 2nd doctor. They order the tests from the other doctor and rerun only if questionable.

My original copayment was $5. I think, when I stopped working in 2002, my copayment was $15. Now Dr. Levin gets up to $50 copayments for a 15 minute session. Increasing copayments also increases income, even if reiumbursements are frozen.

Health care should never have evolved into being associated with employment. Profit-making insurance companies should not be involved in health care. Nevertheless, insurance is there and the US government seems to think private insurance is the ideal for its citizens.

I worked in a really low paid one-on-one situation with no prestige as a public welfare worker. Also, I have done some charitable work through churches. You can never meet all the need. The client, patient, or whoever, always wants more. Dr, Levin publicly confessed some bizarre time-chinchy behavior with 2 patients.

Not sure how many docs I’m talking with here, but you are open-minded. After getting my SS disability and Medicare, docs seem to take me seriously and don’t see my health problems as a game to get more insurance money.
I get home health care and also see a private internist, endocrinologist, and a dermatologist.
I don’t think my internist, endo, or derm view me as an “indigent.” I think they view me as a “patient” whom the government has already designated as disabled.
My father finally realized he could quit messing with the VA, and pay his annual deductible and then go for 20% after that. That’s what I do.
It’s sad that working sick are caught in endless insurance traps with ever-increasing costs.
I have a daily home health nurse, an LVN, who helps me with insulin. Of course, Medicare can be tacky about paying for that too. I point out that he makes me eat regularly and take my insulin regularly and my doses goes down all the time. Sure, he knows a lot more about my health than any of the docs.
My home health providers are more likely to regard me as “indigent” than my private doctors.
I won’t pay a psychiatrist at this time.. As you know, Medicare only pays psychs half. I could go to the local mental health authority and get the rest subsidized.
we need psychiatrists. I have hypothryroidism and am in the thyroid spectrum that later developed diabetes. In the early stages of diabetes, I was hopelessly depressed and mental drugs would not help. When my sugar fell below under 140, I felt rosy. Psychologists are not trained to understand the many biological illnesses that affect the mind.
If a person is willing to pay $180 cash for an hour of your time, take the money.
However, I feel that all American medical and dental school graduates have social responsibility too.
None of you paid for all of your education expense.
Most of you went to school on a buy now, pay later plan. But you want cash up front in your offices!
I feel entitled to a good life also. I have a year oflaw school. I’d feel entitled with just my HS diploma.

i just wish i could find a Psychiatrist who does therapy. As it is, there is one i desperately want to see, however, he is not taking patients. (i saw him when he was a Fourth Year Resident and he was just amazing, i was so very stable during those 10 months) After seeing many non-MD’s and having very bad experiences, i don’t trust anyone but an MD.
tracy

In many parts of the U.S. psychiatrists mostly prescribe medication. So finding a psychiatrist who offers psychotherapy depends on where you live. Besides asking your primary care doctor and trusted friends, you might check with the psychiatry department of a local medical school (or any large medical center) if there is one nearby. A local community mental health clinic (CMHC) or mental health association may know of someone. And you can search online, of course. Good luck.

Thank you for publishing my comments including the criticism about fees.

The med doctors posting here would agree that psychologists are not qualified to evaluate medical diseases in relation to illnesses like diabetes and hypothyroidism.

I have a question about psychiatry. How new is the concept of a psychiatrist “talk doctor” as we know it now? Fees can’t be discussed without a historical context. If you are just prescribing meds, you are usually not doing a bodily exam. You are still “talk doctors.”

“Madness,” “sadness”, or whatever has always been with us. Yes, people used to go the priest or shaman, who may or may not have used chemicals. There have always been a few people who hear voices. Mental institutions have hellish histories with one or two docs in charge of them.

Were psychiatrists ever paid in produce like the old family docs? Did they ever make house calls?

Freud was not the father of psychiatry. There were others. My understanding was, that as a Jew, he was not allowed to work in the mental institutions. Were other psychs seeing patients one-on-one during Freud’s time and prescribing meds?

Sigmund Freud is credited with inventing one of the first forms of psychotherapy, although clinical hypnosis came before this. So “talk doctors” are about 120 years old. The specialty of psychiatry began before this, in the early 1800s, and Freud himself was trained as a neurologist, not a psychiatrist. So he was clearly not “the father of psychiatry,” and to the best of my knowledge never sought work in mental institutions. Until Freud, psychiatrists treated only the severely mentally ill, using whatever medications and other physical treatments that were available at the time. This generally took place in “insane asylums,” large institutions to treat, protect, and (unfortunately) warehouse the mentally ill. I don’t know if psychiatrists ever saw outpatients in the 1800s; I suspect it was rarely if ever.

Betsy, you’ve commented a lot on this particular post. I’m glad you found my writing interesting. But since I run this blog myself, I may not have time to reply to further specific questions. Take care.

It’s cool, Dr. Reidbord. I like you a lot. There is always social progress and there will always be a plethora of new illnesses and diagnoses, like AIDS. In my Gray’s Anatomy. the purpose of the thyroid gland is not known. Insulin is also a relatively new discovery.

I have some complex med problems, but I’ve been relatively stable and had more knowledge of them for years.

You know that there are other illness like diabetes and hypothyroidism that contribute to “thinking,” and that only a psychiatrist is really trained to evaluate and spend more time with people like me.

After my sister had difficulty sleeping following a serious life trauma, she was prescribed Ambien and Xanax. She was told to take the Xanax as needed, up to 4mg/day. She was given no warning about the addictive nature of this med, was not advised to never stop it abruptly, and was not told to keep a steady dose due to the short half life of the pill. She became reclusive and suicidal. Instead of considering that the meds could have instigated this increase in symptoms, she was prescribed more drugs. When she got worse, she was sent to a 3 week outpatient treatment center for more drugs where she left with a total of 7 meds. Upon release, it was suggested that, in addition to being clinically depressed, she might be bi-polar…despite the fact that several months earlier and for her entire 47 years she was a happy, functional person. In the many months since, I have not been able to find a single therapist or psychiatrist who has ANY experience helping people safely off these drugs, in fact I have spoken to a few who have told me Xanax was not addictive. The therapist say that medications are not their job and the psychiatrists say that she needs the meds, however, they take no more than 15 mins.
As the comment above notes, it probably would be easy and straightforward to write a prescription for pills…I think I could do that as well as anyone else. But, to abide by the code, “Do no harm first”, the role of the psychiatrist here should be to know ALL the implications of using these medications–to know the side effects, the real effectiveness of the drugs based on the actual study results , the possibilities of interdose withdrawal issues, the real potential for addiction, the timeframe for tapering, and the symptoms of withdrawal. They should be able/willing to help their patients get off these meds when indicated and not just keep uping the dosages.
There has been nothing “tediously straightforward” about watching my sister deteriorate under the weight of the drugs and not to have anyone who will take the time to even review her file and try to help us sort out this mess. There are not even safe treatment programs for drugs like Xanax so without the help of doctors we have nowhere to turn
Doing a job well is never easy but at the end of the day doing the right thing matters. I live in Doylestown and when I read the article in the New York Times, I was amazed. If the doc really believed that what he was doing was shortchanging his patients, by the oath he took, he had an obligation to stand against what he saw as harmful to his patients. But instead, he shortchanged them and his profession. And sadly, I have found he is not alone.
If you want to make a difference in your profession, learn about these drugs and help people that are suffering (read the Ashton Manual as a start and you can be the first practitioner who even heard of it–also some of the benzo support group forums) There are many people who, like my sister, just needed some help after the loss of a loved one or a major life trauma and were given drugs that were easy and fast to write by docs that were worried about time and not the long term implications of their actions.

I’m sorry about what happened to your sister — and this is hardly the first time I’ve heard about psychiatrists piling on unneeded medication, misdiagnosing a patient, and mistaking side-effects for a primary psychiatric disorder. But I’ll repeat what I said: Management of most psychiatric medications is tediously straightforward. Just because some of my colleagues are incompetent doesn’t make the work inherently difficult (or interesting). 4 mg a day of Xanax is way too much as an initial prescription, and of course your sister should have been told about addiction risk and other issues. She should not have been misdiagnosed, and she should have received straightforward (there’s that word again) instructions on how to decrease and stop her meds.

I suppose we are going to disagree here. The word management suggests to me not just prescriping the drugs, but making sure that they are used properly and that the risks do not outweigh the benefits. There is no way this should ever been considered straightforward because every person is different and even one mistake can have dire consequences. When you start to see these meds in such a cavalier fashion, you ignore the important weight of each decision that you make and the impact it can have on a persons life.
Thanks for taking the time to write this interesting blog.

Michele,
I don’t see our disagreement. I concur with your definition of medication “management” (there’s more to it as well). And I just wrote that cavalier prescribing is professionally incompetent.

Nonetheless, it is straightforward to go through a diagnostic checklist or equivalent to assess the indications for antidepressant or anti-anxiety medication; to consider contraindications, medication interactions, and the like; to discuss the risks and benefits with the patient; to write a prescription; and to arrange for follow-up. This may sound like a lot, but it’s mostly done by primary care providers such as family doctors and nurse practitioners, in the midst of treating sore throats, ear aches, and back pain. As part of a general medical practice, such cases are pretty routine but not tedious, because psychiatric problems are mixed in with many others.

As a psychiatrist, assuming I conducted a rushed and impersonal interview, I could see a new patient every 15 or 20 minutes, just like Dr. Levin in Doylestown. One depressed and/or anxious person after another, all day, every day (with an occasional bipolar or schizophrenic or OCD patient here and there). Man, that would be tedious. I would be bored and irritated, and over time I might become cavalier and cynical.

Naturally, I don’t do this. A psychotherapeutic approach, with or without medications, sees each patient as different, not simply a member of a diagnostic category. I could see only depressed people all day long and it would stay interesting. Each patient is unique. And even if I see someone for “meds only”, I do an hour-long evaluation. I hardly need an hour to write a simple prescription, but I see my specialty as a lot more than that.

The point of my post was that we psychiatrists can see uncomplicated patients every 20 minutes and dole out prescriptions. It’s just a terribly bad idea. It shortchanges patients and maligns our profession. And because it’s tediously straightforward, it saps our spirit and promotes the cavalier attitude you rightly condemn.

Thank you for clarifying the discussion. Clearly, we are in agreement. Forgive me if I improperly read your remarks. It has become very easy for me to be skeptical and suspicious of your profession. Hopefully, in the future, more practitioners will follow your lead and commit themselves to pointing out the flaws in our system that limit the time needed for doctors to properly treat their patient. I enjoyed the discussion.

Hi, I am not a doc but was seeing a psychiatrist with my husband for a long time. He chose her, quit going, filed for divorce and then refused to pay her (even though court ordered to do so). I am a brain tumor patient with two actively growing tumors and thanks to surgery and radiation, along with the precarious location of my tumors (I’ve lost vision, memory, have disabling nausea, tremors, fatigue and more every day) and my husband’s adulterous affair, I am in need of therapeutic help. I am facing a second brain surgery next week, alone. I have an abusive family, a once loving but now abusive husband (who took me to trial for the divorce although we have no kids, no business to split, etc.) and no help of any kind. As my psychiatrist went without payment from my husband (the sole moneymaker), she had no choice but to drop me as a patient THREE times, the last one final. My husband even went so far as to harass her via email and show up at her office in person. If ever a person needed a doc that works as both therapist and med writer, it is me however, due to my newly imposed financial constraints (while he keeps me locked out of our East Hampton home, takes his mistress, her kids and mom on lavish vacations, and paid for her master’s degree) I need a psychiatrist who will accept my insurance co-pays. Living in NYC it is almost impossible to find a psychiatrist who will do therapy, write the scripts and accept the insurance. I have been without a therapist since June 2. It is almost October. I tried to find a social worker at the hospital where I’ll be having surgery next week and was told that one would not speak with me until after my surgery. I will be in no shape to have a coherent conversation AFTER BRAIN SURGERY. I am acting as my own advocate, poorly although the truth is no one could do better. Psychiatrists don’t want to do both and in my case, with a massive brain issue, an understanding of the brain chemistry and a bit of biology is necessary to treat me. A psychologist on their own cannot do this. And so I sit and wait, for a court to decide, for my husband to further punish me (I know not what for) and a psychiatrist in Manhattan who will do therapy, write scripts and take co-pays. Wish me luck. thanks!

In addition to wishing you luck, I have a thought or two. If there’s any place in America where psychiatrists do psychotherapy, it’s Manhattan. So I assume your challenge in finding a psychiatrist who offers both this and medication is economic. That is, it’s hard to find a private practice psychiatrist who accepts “insurance co-pays” as full payment. (To be honest, I’m not sure if you mean you have insurance but can’t pay the out-of-pocket co-pay, or that you don’t have insurance and seek to pay only as much as your insurance co-pay would be.) This is particularly challenging if you’re cold-calling without a referral, and have a complex problem such as a brain tumor. I wonder how you’re avoiding same problem with your surgery itself: Are the surgeons accepting insurance co-pays? Is the hospital?

Sometimes doctors, including psychiatrists, will take on low-fee (or “sliding scale”) patients. But if you’ve been looking since June, you might consider teaching hospitals and/or training clinics instead. The front line staff are not very experienced, but they are supervised by faculty who usually have good professional reputations. And most would enthusiastically welcome an “interesting teaching case” like yours. In any case, I do wish you good luck.

Hi Steven, Yes, my challenge in finding a psychiatrist who offers both therapy and medication is economic. And yes you are right it’s hard to find a private practice psychiatrist who accepts “insurance co-pays” as full payment. Forgive my lack of clarity about having insurance,I could blame it on the brain tumors but it’s just me being human. I do fortunately still have health insurance coverage which my husband is paying. HOWEVER when my husband ignores court orders and does not fill the credit card with the court ordered available balance for me to use for medical purchases, treatment, medicine, I cannot afford the out of pocket co-pay OR any of the meds or especially my out of network doctors, docs he specifically chose for me, once upon a love of me. He chooses doctors for himself and the loved one of the moment by real estate. If they can afford the rent on Park or Fifth, they must be good. That’s why he wants me in Paterson now. Yes it is a complex issue, brain tumor, physical abuse (first husband), verbal, emotional and financial abuse (second husband). As for getting my surgery paid, YES surgeons are fortunately accepting the insurance co-pays (even more fortunately my neurosurgeon is a genius!) and so are hospitals OR they just take what they can get and act humane about it, yes hard to believe from the rep hospitals have. I am aware of the sliding scale theory or practice but on paper I’m a rich woman – house in the Hamptons with pool and tennis, a house I’ve been locked out of for over two years, three homes, one a 1,750 sq ft loft with terrace in Midtown by Columbus Circle (Time Warner South). I may have just stumbled upon an in network psychiatrist the other day, after my brain surgery tomorrow and when I’m up and walking again, I will have my second appointment with her and see how it goes however the copay from my pocket (with holes in it) will be tough to come up with AND insurance only allows 30 sessions. In my case, with all I am forced to endure, death wishes from my husband, harassing emails from as of yet ‘unknown’ senders, physical harm from losing physicians and medicine, and growing legal bills, I need more sessions than most, oh and that nasty brain tumor growing thing is a bother! Thanks for your time, compassion and suggestions.

Hi Altostrata. If you read the comments above, especially those to and from Michele B, you’ll see that my phrase “tediously straightforward” refers to a psychiatric practice monotonously laden with medication visits for depression and anxiety, the most common psych presentations. It says nothing about how often mistakes are made, nor does it preclude occasional interesting/difficult cases. I also note that the same cases seen in the more varied mix of a primary care practice are not “tediously straightforward.” In other words, the phrase refers to the practice, not to the patients.

The study reported in Science Daily demonstrates that side-effects are better captured by a comprehensive questionnaire than by a clinician asking, “Is anything bothering you?” If the goal were not to miss any side-effects, say for research purposes, a questionnaire would undoubtedly be better. That’s not the goal in clinical practice. The relevant clinical questions are whether a prescribed medication is doing any good, and whether it’s doing any harm. Insignificant side-effects don’t count. The article reports that the questionnaire is two or three times (not 20 times) better than usual practice at detecting significant, harmful side effects. The base rate is important here. If a 15-minute questionnaire, i.e., one that doubles the duration of the med-check, boosts the detection of actionable side effects from 2% to 4% of patients, it may not be worth it. If the numbers are 15% and 45% respectively, it surely would be. In any case, reviewing dozens of these questionnaires every day would be tediously straightforward too.

The other article, from the Wall Street Journal, doesn’t say that psychiatrists or non-psychiatric MDs “often” misdiagnose medical disease as psychiatric. No statistics about misdiagnosis are cited at all. Instead, the article quotes psychiatrists and a neuropsychologist who are careful to test for medical causes. Are true medical conditions sometimes dismissed as “merely” psychiatric? Certainly. Are psychiatric conditions sometimes wrongly treated as medical conditions? Yes, that happens too. It would be great if psychiatric conditions were better understood, wouldn’t it?